For an adult with a single‑level degenerative lumbar disc herniation or mild central stenosis who is a candidate for minimally invasive decompression and has no severe osteoporosis, multilevel disease, or infection, how does uniportal endoscopic spine surgery compare to biportal endoscopic spine surgery regarding efficacy, safety, and recovery?

Uniportal vs. Biportal Endoscopic Spine Surgery for Lumbar Decompression

For adults with single-level degenerative lumbar disc herniation or mild central stenosis requiring minimally invasive decompression, biportal endoscopic spine surgery provides superior decompression efficacy and better functional outcomes compared to uniportal techniques, particularly for bilateral symptoms, though uniportal offers advantages in operative time and early postoperative back pain relief. 1

Efficacy and Clinical Outcomes

Decompression Adequacy

• Biportal endoscopy achieves significantly greater postoperative dural sac expansion compared to uniportal techniques, with a mean difference of 59.01 mm² (95% CI: 21.29 to 96.73), indicating more complete neural decompression 2
• For patients with bilateral symptoms, biportal technique demonstrates superior relief of mild-side lower extremity pain at 3 months and 12 months postoperatively compared to uniportal 1
• Both techniques provide comparable decompression for severe stenosis (Schizas Grade C or D), with significant increases in thecal sac cross-sectional area in both groups 3

Functional Recovery

• Biportal endoscopy produces significantly better functional outcomes, with ODI scores notably lower at 3 months and 12 months postoperatively compared to uniportal, while uniportal ODI scores did not significantly differ from preoperative values 1
• The excellent and good response rate at 12 months is significantly higher with biportal (94.23%) versus uniportal (81.25%) based on modified Macnab criteria 1
• For isolated disc herniation, both techniques show comparable VAS and ODI scores at final follow-up, with no significant differences in long-term pain relief 4, 2

Safety Profile

Perioperative Complications

• Complication rates are equivalent between techniques, with no significant difference in overall adverse events (OR = 0.82; 95% CI: 0.31 to 2.12) 2
• Both approaches demonstrate safety profiles superior to open discectomy, with biportal showing less paravertebral muscle injury (4.50 ± 0.60 vs. 11.42 ± 0.87 for open) at 1 year 3

Blood Loss

• Biportal endoscopy results in less intraoperative blood loss (mean difference -2.54 mL, 95% CI [-4.48, -0.60], p = 0.01) compared to uniportal 4
• When compared to open discectomy, biportal demonstrates significantly less estimated blood loss (41.5 ± 22.2 mL vs. 111.2 ± 25.0 mL, p < 0.05) 3

Recovery Parameters

Operative Time and Hospital Stay

• Uniportal technique offers shorter operative time (mean difference 17.14 minutes, 95% CI: 6.52 to 27.76) and shorter hospital stay (mean difference 2.12 days, 95% CI: 0.35 to 3.90) compared to biportal 2
• For lumbar disc herniation specifically, uniportal demonstrates even greater operative time advantage (mean difference 31.67 minutes, 95% CI: 12.44 to 50.90) 2
• Biportal still provides shorter hospital stay (4.0 ± 1.4 days) compared to open discectomy (6.8 ± 1.6 days, p < 0.05) 3

Early Postoperative Pain

• Uniportal endoscopy provides significantly better early back pain relief within 3 days of surgery (WMD = 0.69,95% CI [0.02,1.37], p = 0.04) compared to biportal 4
• This early advantage does not persist beyond 3 months, with no significant differences in VAS for back pain at 3 months or final follow-up between techniques 4

Clinical Decision Algorithm

Choose Biportal When:

• Patient presents with bilateral symptoms or bilateral stenosis, as biportal achieves more complete bilateral decompression 1
• Severe stenosis (Schizas Grade C or D) requires extensive decompression 3
• Functional recovery and long-term disability reduction are primary goals 1
• Patient can tolerate slightly longer operative time for superior decompression 2

Choose Uniportal When:

• Unilateral disc herniation without significant bilateral pathology is present 2
• Minimizing operative time is critical due to patient comorbidities 2
• Early mobilization and same-day discharge are prioritized 4
• Patient desires fastest return to activity with acceptable functional outcomes 4

Critical Pitfalls to Avoid

• Do not select uniportal for bilateral stenosis expecting equivalent bilateral decompression—biportal provides superior contralateral decompression through better visualization and instrument triangulation 1
• Do not assume early back pain advantage of uniportal translates to long-term benefit—this difference disappears by 3 months while functional outcomes favor biportal 4, 1
• Avoid underestimating the learning curve for biportal technique, which requires coordination between two portals but offers enhanced decompression efficiency once mastered 1
• Do not use operative time as sole selection criterion—the 17-31 minute difference is offset by superior decompression and functional outcomes with biportal in appropriate cases 2, 1